Flexible bone screw

ABSTRACT

There is disclosed a device and method for stabilizing a bone. The device includes a flexible threaded portion operable to thread along a curved path in a bone.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application claims the benefit of U.S. Provisional Application No. 62/191,904, filed Jul. 13, 2015, and U.S. Provisional Application No. 62/238,780, filed Oct. 8, 2015, all of which are hereby incorporated by reference.

FIELD OF THE INVENTION

Examples of the invention relate generally to orthopedic devices for the surgical treatment of bone and, more particularly, to the stabilization of bones with an intramedullary device.

BACKGROUND

Orthopedic medicine provides a wide array of implants that can be attached to bone to repair fractures. External fixation involves the attachment of a device that protrudes out of the skin, and therefore carries significant risk of infection. Many fractures in long bones can be repaired through the use of bone plates, which are implanted and attached to lie directly on the bone surface. The bone plate then remains in the body long enough to allow the fractured bone to heal properly. Unfortunately, such bone plates often require the surgical exposure of substantially the entire length of bone to which the plate is to be attached. Such exposure typically results in a lengthy and painful healing process, which must often be repeated when the implantation site is again exposed to allow removal of the plate. There is a need in the art for implants and related instruments that do not require such broad exposure of the fractured bone, while minimizing the probability of infection by avoiding elements that must protrude through the skin as the bone heals.

SUMMARY

Examples of the invention provide devices and methods for stabilizing first and second bone portions relative to one another.

In one example of the invention, a bone screw includes an elongate body having a distal portion, a mid-portion and a proximal portion spaced longitudinally relative to a longitudinal axis. The distal portion includes a helical thread having a major diameter and a minor diameter. The mid-portion has a non-threaded outer surface with an outer diameter. The mid-portion outer diameter is equal to or greater than the thread major diameter and the distal threaded portion is operable to bend as it is threaded into a bone to follow a curved path.

In another example of the invention, a plurality of bone screws includes first and second bone screws each having an elongate body having a distal portion, a mid-portion and a proximal portion spaced longitudinally relative to a longitudinal axis. The distal portion of each screw has a helical thread formed on it having a minor diameter, a pitch and a major diameter. The second bone screw thread minor diameter is equal to the first bone screw thread minor diameter, the second bone screw thread pitch is equal to the first bone screw thread pitch, and the second bone screw thread major diameter is greater than the first bone screw thread major diameter.

In another example of the invention, a bone screw includes an elongate body having a distal portion and a proximal portion spaced longitudinally relative to a longitudinal axis. The distal portion has a helical thread formed on it. The thread has a major diameter and a minor diameter. The distal threaded portion is operable to bend as it is threaded into a bone to follow a curved path. The threaded distal portion has a bending stiffness that is less than the bending stiffness of the proximal portion.

In another example of the invention, a method of inserting a screw into a bone includes selecting a bone screw comprising an elongate body having a distal portion, a mid-portion and a proximal portion spaced longitudinally relative to a longitudinal axis, the distal portion having a helical thread formed thereon, the thread having a major diameter and a minor diameter, the mid-portion having a non-threaded outer surface with an outer diameter, the mid-portion outer diameter being equal to or greater than the thread major diameter; forming a curved tunnel in a bone; and turning the threaded distal portion of the bone screw into the tunnel so that the threaded distal portion bends to follow the curve of the tunnel.

In another example of the invention, a method of inserting a screw into a bone includes selecting a bone screw from a plurality of bone screws including a first bone screw comprising an elongate body having a distal portion, a mid-portion and a proximal portion spaced longitudinally relative to a longitudinal axis, the distal portion having a helical thread formed thereon, the thread having a minor diameter, a pitch and a major diameter; and a second bone screw comprising an elongate body having a distal portion, a mid-portion and a proximal portion spaced longitudinally relative to a longitudinal axis, the distal portion having a helical thread formed thereon, the thread having a minor diameter, a pitch and a major diameter; the second bone screw minor diameter being equal to the first screw minor diameter, the second bone screw pitch being equal to the first screw pitch, and the second bone screw major diameter being greater than the first screw major diameter; forming a tunnel in a bone; turning the selected bone screw into the tunnel.

BRIEF DESCRIPTION OF THE DRAWINGS

Various examples of the invention will be discussed with reference to the appended drawings. These drawings depict only illustrative examples of the invention and are not to be considered limiting of its scope.

FIG. 1 is a side elevation view of a screw according to one example of the invention;

FIG. 2 is a detail view of the screw of FIG. 1;

FIG. 3 is a detail view of the screw of FIG. 1;

FIG. 4 is an end view of the screw of FIG. 1;

FIGS. 5-7 are side elevation views of a set of differently sized screws like that of FIG. 1;

FIGS. 8-10 are partial sectional views showing the insertion of the screw of FIG. 1 into bone;

FIGS. 11-35 illustrate a surgical procedure utilizing the bone screw of FIG. 1;

FIG. 36 is a perspective view of a screw according to one example of the invention;

FIG. 37 is a top plan view of the screw of FIG. 36;

FIG. 38 is a side elevation view of the screw of FIG. 36;

FIG. 39 is an end view of the screw of FIG. 36;

FIG. 40 is a sectional view taken along line 40-40 of FIG. 37;

FIG. 41 is an exploded sectional view taken along line 40-40 of FIG. 37;

FIG. 42 is a cross sectional view of a screw similar to the screw of FIG. 36 according to one example of the invention; and

FIG. 43 is an exploded cross sectional view of the screw of FIG. 42.

DESCRIPTION OF THE ILLUSTRATIVE EXAMPLES

The term “transverse” is used herein to mean not parallel. FIGS. 1-4 depict a bone screw 100 having an elongate body 102 with a distal portion 104, a mid-portion 106 and a proximal portion 108 spaced longitudinally relative to a longitudinal axis 110. The distal portion 104 includes a helical thread 112 having a major diameter 114, a minor diameter 116, and a pitch 128. The mid-portion 106 has a non-threaded outer surface 118 with an outer diameter 120. In the illustrative example of FIGS. 1-4, the mid-portion outer diameter 120 is equal to or greater than the thread major diameter 114. The distal threaded portion 104 is operable to bend as it is threaded into a bone to follow a curved path. For example, the bending stiffness of the distal threaded portion 104 is such that it will bend to follow a curved path in human bone. Such a curved path may be defined, for example, by a curved hole in the bone, a guide wire, or a natural bone feature such as a non-linear intramedullary canal bounded by cortical bone. This is distinct from prior art screws which if started on a curved path in human bone would, when advanced, continue in a straight line and thus deviate from the curved path and form their own, straight, path through the bone. Preferably the bending stiffness of the threaded distal portion 104 is lower than the bending stiffness of the mid-portion 106. The relatively lower bending stiffness of the threaded distal portion 104 causes the threaded distal portion to bend to follow a curved path while the relatively higher bending stiffness of the mid-portion causes the mid-portion to remain straight to stabilize first and second bone portions relative to one another at a bone interface such as at a fracture, osteotomy, or fusion site. The difference in bending stiffness between the threaded distal portion 104 and the mid-portion 106 may be achieved in different ways. For example, the threaded distal portion 104 and the mid-portion 106 may be made of different materials and/or may have different sectional moduli. In the illustrative example of FIGS. 1-4, the threaded distal portion 104 and the mid-portion 106 have different sectional moduli. The threaded distal portion minor diameter 116 is less than the outer diameter 120 of the mid-portion 106 and the threaded distal portion major diameter is less than or equal to the outer diameter 120 of the mid-portion 106. Preferably, the ratio of the bending stiffness of the mid-portion 106 to the bending stiffness of the threaded distal portion 104 is in the range of 1.5:1 to 100:1. More preferably, the ratio is in the range of 2:1 to 20:1. For example, screws suitable for internal fixation of a clavicle fracture and that fall within these ranges may have a major diameter 114 in the range of 4-6.5 mm, a minor diameter 116 in the range of 2.5-3.5 and a cannulation 101 with a diameter in the range of 1-2 mm. Preferably, the screw 100 is made of a polymer.

Table 1 compares the calculated load required to bend a cantilevered tube of 3 mm outside diameter and 1.5 mm inside diameter around a radius of 50 mm and an arc length of 26 mm. The titanium and stainless steel alloys are predicted to have a required load approximately 10 times that of the PEEK and PLLA. These loads would be greater than the bone could withstand and a threaded device made of those materials would not follow a curved path in the bone but would instead cause the bone to fail. In the case of the highly cold worked stainless steel, even if the bone could withstand the load, the screw would fail since the minimum bend radius before failure of the screw is greater than 50 mm.

TABLE 1 Load at 50 mm bend radius Yield Failure Yield Failure Flexural Stress Stress Strain Strain Modulus Load Material (MPa) (MPa) (%) (%) (MPa) (N) PEEK 100 115 2.5% 20% 4 9.8 ASTM F2026 PLLA 90 100 2.6% 25% 3.5 8.7 Ti—6Al—4V 880 990 0.8% 14% 114 91.7 ELI ASTM F136 316LVM 1468 1696 0.7% 3% 197 Not Stainless Steel possible ASTM F899

Another way to quantify the bending stiffness of the threaded distal portion 104 is by the amount of torque required to turn the threaded distal portion 104 into a curved bone hole having a specified radius of curvature. For example, the threaded distal portion 104 preferably requires a torque less than 20 in-lbs to turn the distal threaded portion 104 into a bone to follow a curved path having a radius of curvature of 50 mm. More preferably the required torque is less than 10 in-lbs. More preferably the required torque is less than 5 in-lbs. More preferably the required torque is approximately 2 in-lbs.

Table 2 compares the measured torque required to advance a threaded tube 25 mm into a 50 mm threaded radius formed in a rigid test block. The tubes were all machined to the same geometry but of different materials. The thread major diameter was 4.25 mm, the minor diameter was 3.0 mm and the inner diameter of the tube was 1.5 mm. A rigid block was prepared having a curved, threaded path. Such a path has a pitch that is wider on the outside of the curve and a pitch that is narrower on the inside of the curve corresponding to the shape of the screw thread when it is curved. Multiple samples of each screw were inserted into the block over an arc length of 25 mm. The maximum torque for each revolution was measured and it was found that the torque increased for each revolution. In Table 2, the range is the range of torque values from the first to the last revolution. The average is the average of the torque values for all revolutions. The peak is the highest torque value and in all cases occurred in the last revolution. However, the torque values for each material were relatively constant over the last few revolutions. The titanium and stainless steel alloys had measured torque values approximately 10 times that of the PEEK. These tests were conducted using a threaded block made of tool steel with a strength greater than that of the materials being tested in order to compare the torque values. As pointed out relative to Table 1, the loads generated from the metal implants would be greater than the bone could withstand and a threaded device as described herein made of these metals would not follow a curved path in the bone but would instead cause the bone to fail.

TABLE 2 Torque to thread around rigid 50 mm radius Material Range (in-lbs) Average (in-lbs) Peak (in-lbs) PEEK  0-2.0 1.4 2.0 ASTM F2026 Ti—6Al—4V ELI 0.7-25 16 25 ASTM F136 316LVM 0.5-20 13 20 Stainless Steel ASTM F899

In addition to bending stiffness advantages, having the threaded distal portion major diameter less than or equal to the outer diameter 120 of the mid-portion 106 allows the distal threaded portion 104 to pass through a passage in a bone that will be a sliding or press fit with the mid-portion 106. A screw so configured, as shown in the illustrative example of FIGS. 1-4, can have an intramedullary canal filling mid-portion 106 providing solid support to a bone interface and a relatively bendable distal threaded portion 104 following a curved path such as for threading into a distal portion of a curved bone to secure the screw in the bone.

The proximal portion 108 may be identical to the mid-portion 106. Alternatively, the proximal portion may have a positive driver engagement feature (not shown) such as internal or external non-circular surfaces, profiles, or holes. For example, an internal or external slotted, threaded, triangular, square, hexagonal, hexalobular, or other drive feature may be provided. In addition, as shown in the illustrative example of FIGS. 1-4, the proximal portion 108 may include an optional external helical thread 122 able to engage a bone portion to provide proximal fixation of the screw. For example, the proximal thread 122 may have a major diameter 124, a minor diameter 126, and a pitch 130 wherein the proximal thread minor diameter 126 is equal to the mid-portion outer diameter 120. In the illustrative example of FIGS. 1-4, the mid-portion outer diameter 120 is equal to the proximal thread minor diameter 126 and the distal thread major diameter 114. The proximal portion may alternatively, or in addition, receive a locking member such as a pin or screw transverse to the longitudinal axis to lock a proximal bone portion to the nail. The locking member may be drilled through the proximal portion. Preferably, the proximal portion has one or more transverse holes formed through it for receiving the locking member.

The distal and proximal thread pitches 128, 130 may advantageously be the same or different depending on the application. For example, to stabilize a fracture, the screw 100 may be inserted into a bone across the fracture so that the distal thread 112 is engaged with bone distal to the fracture and the proximal thread 122 is engaged with bone proximal to the fracture. If the bone portions on either side of the fracture are reduced to a desired final position prior to inserting the screw 100, then it is advantageous for the thread pitches 128, 130 to be equal so that insertion of the screw does not change the relative positions of the bone portions. If on the other hand, it is desirable to move the bone portions relative to one another by the action of inserting the screw then it is advantageous for the pitches 128, 130 to be different. For example, to move the bone portions closer together to reduce the fracture, the distal thread pitch 128 may be made greater than the proximal thread pitch 130 so that with the distal thread 112 engaged distally and the proximal thread 122 engaged proximally, further advancing the screw causes the distal bone portion to move proximally relative to the screw faster than the proximal bone portion moves proximally and thus move the bone portions closer together. Alternatively, to move the bone portions further apart to distract the fracture, the distal thread pitch 128 may be made smaller than the proximal thread pitch 130 so that with the distal thread 112 engaged distally and the proximal thread 122 engaged proximally, further advancing the screw causes the distal bone portion to move proximally relative to the screw more slowly than the proximal bone portion moves proximally and thus move the bone portions further apart. Preferably, the bone screw 100 has a through bore, or cannulation 101, coaxial with the longitudinal axis 110 to permit the bone screw 100 to be inserted over a guide wire.

The bone screw 100 of FIGS. 1-4, may advantageously be provided in a set containing a plurality of bone screws as shown in the illustrative example of FIGS. 5-7. For example, it is advantageous in a surgical procedure to minimize the number of steps and the amount of time needed to complete the procedure. In a bone fixation procedure, a surgeon often makes an initial sizing decision based on medical imaging. During the procedure, it may become expedient to change the predetermined size based on observation of the surgical site or the fit of trial implants or instruments. For example, a surgeon may determine initially that a smaller bone screw is appropriate. However, during preparation of the site, the surgeon may determine that a larger screw will better grip the bone or fill, for example, a canal in the bone. The illustrative set of bone screws shown in FIGS. 5-7 facilitates changing between sizes. Each screw 140, 150, 160 in the set has a minor diameter 142, 152, 162, a major diameter 144, 154, 164, and a pitch 146, 156, 166. The minor diameters 142, 152, 162 are equal to one another so that a single diameter drill will provide an initial bore hole appropriate for all the screws in the set. The pitches 146, 156, 166 are equal to one another so that all of the screws in the set will threadably engage a helical thread of the same pitch. The major diameters 144, 154, 164 may increase to provide progressively more bone purchase or, for example, to span increasing larger intramedullary canals. For example, with the set of screws of the illustrative example of FIGS. 5-7, a surgeon may drill a hole equal to the minor diameters 142, 152, 162 and then tap the hole with a tap corresponding to the thread of the smallest major diameter screw 140. The tactile feedback received by the surgeon as the tap is inserted will indicate to the surgeon if the thread major diameter is sufficient to provide a desired level of bone engagement. For example, the surgeon can feel if the tap is engaging the cortical walls of an intramedullary canal or if the tap is in softer cancellous bone. If the surgeon determines that greater engagement is desired, the surgeon can next tap the hole with a tap corresponding to the thread of the next larger major diameter screw 150. Since the minor diameters 142, 152, 162 and thread pitches 146, 156, 166 are the same for all of the screws in the set, the next tap will thread into the previously tapped hole and increase the bone thread major diameter without damaging the bone thread. Once the desired bone engagement is achieved, the surgeon may then insert the desired screw 140, 150, 160. If in tapping the larger major diameter thread, the surgeon determines that the bone is providing too much resistance, the surgeon may revert to the smaller sized screw since the threads are still compatible. Alternatively to using a separate tap, the screw threads may be configured as self-tapping so that the screws may be threaded directly into the bored hole.

In addition to the sizing advantages of having the same minor diameter 142, 152, 162 across a family of screws, it is also advantageous because the distal threaded portion of each screw will have a similar bending stiffness to each of the other screws 140, 150, 160 since the continuous wall of the minor diameter contributes much more to the bending stiffness than the helical thread itself. This similar bending stiffness means that they can be inserted around a similar bending radius with a similar torque.

In the illustrative example of FIGS. 5-7, each screw 140, 150, 160 has a mid-portion diameter 148, 158, 168 equal to the corresponding major diameter 144, 154, 164. The increasing mid-portion diameters provide progressively less flexible mid-portions across the set of screws and, for example, canal filling for increasingly larger bones if used in the intramedullary canal. If the screws incorporate the optional increasing mid-portion diameter as shown, then it is desirable to re-drill the mid-portion of the bone hole to accommodate the mid-portion when an increase in screw size is desired. However, the distal, threaded portion of the bone hole does not need to be re-drilled so the screw threads will not be damaged by drilling.

Alternatively to, or in addition to, the threaded distal portion 104 and mid-portion 106 having different sectional moduli, the threaded distal portion 104 and mid-portion 106 may have different material properties such as two different materials or different conditions of the same material to produce a difference in bending stiffness between them.

In the illustrative example of FIGS. 36-41, a screw 170 has separate first and second members 172, 174 permanently joined together. The first member 172 includes an elongate body 176 with a proximal end 178, a distal end 180, a longitudinal axis 182, and an axial through bore 184. The proximal end 178 of the first member includes a pair of transverse through bores 181, 183. Each transverse bore 181, 183 defines a longitudinal axis and the axes form an angle 185 between them about the longitudinal axis 182 as best seen in FIG. 39. Providing more than one transverse through bore increases options for attaching the screw to bone fragments and options for fixation direction. Both bores may be used for fixation or the one that is most conveniently located. Preferably the angle 185 is in the range of 0 to 90 degrees. More preferably the angle 185 is in the range of 20 to 90 degrees. In the illustrative example of FIGS. 36-41, the angle 185 is 45 degrees. The proximal end 178 also includes opposed flats 187 for engaging a driver in torque transmitting relationship. An internal thread 189 within the bore 184 is engageable with, e.g., a threaded draw bar to secure the first member to a driver.

The second member 174 includes an elongate body 186 with a proximal end 188, a distal end 190, a longitudinal axis 192, an external helical thread 194, and an axial through bore 196. The distal end 180 of the first member 172 and the proximal end 188 of the second member 174 may have complementary geometries to aid in joining them. In the illustrative example of FIGS. 36-41, the distal end 180 of the first member has a stepped conical taper and the proximal end 188 of the second member has a corresponding stepped conical socket 198. The mating surfaces may be any suitable shape as determined by the materials and joining technique including but not limited to plug and socket joints (as shown), scarf joints, butt joints, dovetail joints, finger joints, and lap joints. The joint may be reinforced with a third component such as an adhesive, pin, or key. The joint may be formed by mechanical interlock, chemical bonding, molding, welding or other suitable joining process. The final assembled screw 170, has a distal portion 191, a mid-portion 193, and a proximal portion 195 and may have the thread forms, diameters, and relationships as described relative to the examples of FIGS. 1-7.

The first and second components 172, 174 may be made of different materials or different conditions of the same material. For example, they may be made of polymers, metals, or ceramics. Metals may include stainless steel alloys, titanium, titanium alloys, cobalt-chromium steel alloys, nickel-titanium alloys, and/or others. Polymers may include nonresorbable polymers including polyolefins, polyesters, polyimides, polyamides, polyacrylates, poly(ketones), fluropolymers, siloxane based polymers, and/or others. Polymers may include resorbable polymers including polyesters (e.g. lactide and glycolide), polyanhydrides, poly(aminoacid) polymers (e.g. tyrosine based polymers), and/or others. Other possible materials include nonresorbable and resorbable ceramics (e.g. hydroxyapatite and calcium sulfate) or biocompatible glasses. They may be made of homogenous materials or reinforced materials. They may be made of crystallographically different materials such as annealed versus cold worked. It is preferable for the mid portion 193 to have a higher bending stiffness than the distal portion 191 and the distal portion should have a bending stiffness low enough for it to be inserted along a curved path in bone.

In a first example, the first component may be made of a metal with a relatively high degree of cold work and the second component of a metal with a relatively low amount of cold work such as for example annealed and cold worked stainless steel. The components may be joined for example by welding. However, as discussed relative to Table 1, most metals are far too stiff to allow threading along a curved path in a bone within suitable torsional loads.

Preferably the distal portion is made of a polymer. In a second example, the first component is made of a metal, such as stainless steel or a titanium alloy, and the second component is made of a polymer such as polyetheretherketone (PEEK) or a polylactide polymer (e.g. PLLA). The components may be joined such as for example by threading them together.

Preferably both components are made of polymers. In a third example, the first and second components are both made of non-resorbable polymers. For example, the first component may be made of fiber reinforced PEEK (e.g. Invibio PEEK-Optima™ Ultra-Reinforced) and the second component may be made of neat (unreinforced) PEEK (e.g. Invibio PEEK-Optima™ Natural). The fiber reinforced PEEK is strong while the neat PEEK is relatively flexible allowing it to be easily threaded around a curved path even while having a relatively large bone filling diameter. The components may be joined, e.g. by molding the components as a continuous matrix with first component fiber reinforcement and second component neat polymer with polymer chains extending across the joint interface. In the example of FIGS. 36-41, the second component is relatively more transparent to laser radiation than the first component and the parts are joined by laser welding at the conical interface. The laser energy passes relatively easily through the second component and is absorbed by the first component so that localized heating at the conical interface takes place causing the polymer constituent of the two components to fuse together.

In a fourth example, the mid-portion and distal portion are made of resorbable polymers. For example, the mid-portion may be made of a glass fiber reinforced PLLA (e.g. Corbion-Purac FiberLive™) and the distal portion may be made of neat PLLA.

Alternatively, the first member 172 and second member 174 may form one continuous part with different properties between first and second portions. The difference in properties may be achieved, for example, by different processing (e.g. thermal processing) or blending materials. For example, different polymers may be combined in a single injection mold cavity and formed together. The polymers may be blended so that there is a transition between them. In another example, stiffening and/or strengthening material, e.g. fibers, whiskers, and/or granules, may be selectively incorporated in, e.g., the first portion.

FIGS. 42 and 43 illustrate an example of a screw 270 similar to that of FIGS. 36-41 except that the first member 272 is not cannulated, the first member 272 extends the full length of the second member 274, and the transverse holes 281, 283 are coplanar. The screw 270 may be assembled as with the prior example including by using complimentary screw threads in the proximal region of the second member 274 and mid portion of the first member 272 as indicated by reference number 250. The screw 270 of the example of FIGS. 42 and 43 may be include any of the materials and features described relative to the prior examples. If, for example, the first member 272 is made of a radiographically more opaque material than the second member 274, then the first member will provide a radiographic marker over the entire length of the screw 270 that may be radiographically visualized during and after surgery to confirm screw placement. For example, a metal first component and polymer second component would provide for radiographic visualization of the metal first component. It has been found by the present inventors that the bending stiffness of the distal end of the screw is not materially changed by eliminating the axial through bore of the first component and is essentially unchanged when the bending stiffness of a guide wire is accounted for which was optionally used with the previous cannulated screw examples. The guide wire is not necessary inasmuch as the screw 270 will follow a curved hole prepared to receive it. The transverse holes 181, 183 may be provided in any number or not at all as desired but it has been found that one is sufficient and two provides the user with additional fixation choice.

FIGS. 8-10 illustrate a bone screw according to the one example of the invention, such as bone screw 100, being inserted into first and second bone portions 200, 202 having a bone interface 204 between them. A first or proximal bore 206 is formed in the first bone portion 200, across the bone interface 204, and into the second bone portion 202. A second or distal bore 208 extends distally from the proximal bore 206 defining a curved path 210. The screw 100 is advanced through the proximal bore 206 until the distal screw threads engage the distal bore 208 as shown in FIG. 9. Further advancing the screw 100 causes it to bend to follow the curved path 210 as shown in FIG. 10. Having a straight portion of the path, and thus the straight mid portion of the screw 100, spanning the bone interface results in a zero stress and strain state at the bone interface which prevents separation of the bone portions 200, 202 at the interface 204.

FIGS. 11-35 depict an illustrative method of using the screw of FIGS. 1-4 to fix a fractured clavicle. A patient is placed in a beach chair position with the head rotated away from the operative side. A bolster is placed between the shoulder blades and head allowing the injured shoulder girdle to retract posteriorly. A C-arm is positioned to enable anterior-posterior (AP) and cephalic views of the operative site. A 2-3 cm incision 300 is made at the fracture site along Langer's Lines running perpendicular to the long axis of the clavicle to expose the fracture site (FIG. 10). The platysma muscle is freed from the skin and split between its fibers. The middle branch of the supraclavicular nerve is identified and retracted.

The medial end 302 of the lateral fragment 304 of the fractured clavicle is elevated from the fracture site incision (FIG. 12).

A K-wire 306, e.g. a 1.4 mm K-wire, is drilled into the canal of the lateral fragment 304 and advanced through the dorsolateral cortex 308 and out through the skin (FIG. 13).

A wire driver is attached to the lateral portion of the K-wire and used to back the wire out until it is lateral to the fracture 310 (FIG. 14). Bone clamps are used at the incision site to reduce the fracture and clamp the bone fragments in position. Proper reduction is confirmed with AP and cephalic radiographic views.

The K-wire 306 is advanced until it is preferably at least 20 mm medial to the fracture (FIG. 15).

A first dilator 312, e.g. a 3.2 mm dilator, is placed over the K-wire and advanced until it contacts the bone (FIGS. 16-17).

A second dilator 314, e.g. a 4.5 mm dilator, is placed over the first dilator 312 and advanced until it contacts the bone (FIG. 18).

A drill guide 316 is placed over the second dilator 314 and advanced until it contacts the bone (FIG. 19).

The first dilator 312 is removed and a first lateral drill 318, corresponding to the minor diameter of the distal screw threads, e.g. a 3.2 mm drill, is advanced over the K-wire into the bone, preferably at least 20 mm medial to the fracture. A drill depth mark readable adjacent the drill guide may be noted as a reference for implant sizing (FIG. 20).

The K-wire is removed and replaced with a flexible guide wire 320, e.g. a nitinol guide wire, sized to fit within the screw cannulation, e.g. a 1.4 mm guide wire. The flexible guide wire 320 is advanced through the first lateral drill and further along the intramedullary canal of the medial bone fragment and will curve to follow the intramedullary canal to define a curved path in the bone. Preferably, the guide wire is advanced approximately 30 mm medial to the tip of the first lateral drill 318 (FIG. 21).

The first lateral drill 318 is removed and a flexible shaft reamer 322, corresponding to the minor diameter of the distal screw threads, is guided over the flexible guide wire 320 to ream the medial portion of the curved path (FIG. 22) The flexible reamer 322 and second dilator 314 are then removed.

A second lateral drill 324, having a diameter corresponding to the diameter of the mid-portion of the screw, e.g. a 4.5 mm drill, is guided over the flexible guide wire to enlarge the bone hole laterally to receive the mid-portion and proximal portion of the screw 100. The second lateral drill 324 is advanced the same distance as the first lateral drill (FIG. 23). The drilling step may be monitored in A/P and cephalic views with the C-arm to avoid perforating the bone cortex as the second lateral drill 324 is advanced into the medial bone fragment 326.

A flexible tap 328, having cutting threads corresponding to the distal threads of the screw 100 is guided over the flexible guide wire to cut threads into the medial bone fragment along the curved path (FIG. 24). The tap may serve as a trial implant and provides tactile feedback regarding the fit of the implant in the bone. If it is determined that a larger screw is desirable, subsequent larger second drills may be used to re-drill the lateral straight portion and subsequent larger flexible taps may be used to increase the distal thread major diameter without having to re-ream the medial curved portion of the bone hole. Once a desired level of thread purchase and canal filling are achieved, a depth mark readable adjacent the drill guide may be noted as a reference for the required implant length. If a screw 100 with a proximal threaded portion is used, a lateral tap may be used to tap the lateral bone fragment to receive the proximal threads.

The screw 100 is attached to an inserter 330 and guided over the flexible guide wire until it is fully seated in the prepared threads in the medial bone fragment (FIGS. 25 and 26). Optionally, the screw 100 may be axially driven with a mallet through the lateral bone fragment until just short of the distal thread engagement. The screw 100 may then be threaded into full engagement with the prepared threads in the medial fragment. Radiographic visualization may be used to ensure that the fracture is fully reduced and anatomically aligned in length and rotation.

If a proximally threaded screw has not been used, or if additional fixation is otherwise desired, cross fixation may be used. For example, a cross fixation guide 340 may be engaged with the implant inserter 330 (FIG. 27). The cross fixation guide may include a knob 342 that threadingly engages the implant inserter 330 and a cross fixation guide sleeve 344 that abuts the lateral bone fragment adjacent the bone hole entrance. Rotating the knob 342 moves the cross fixation guide sleeve 344 and implant inserter 330 axially relative to one another. With the cross fixation guide sleeve 344 abutting the lateral bone fragment 304, the implant inserter, implant, and medial bone fragment 326 will be drawn laterally and the lateral bone fragment 304 will be pressed medially to apply compression across the fracture.

Inner and outer drill sleeves 346, 348 are advanced through the guide 340 until they abut the bone (FIG. 28). In the case of a screw such as screw 170 having one or more preformed transverse bores, the cross fixation guide may have one or more targeting holes positioned to align with the one or more transverse bores. In the case of a screw such as screw 100 not having preformed transverse bores, cross fixation may be inserted directly through the screw 100 forming a transverse bore intraoperatively.

For example, a cross fixation wire 350 may be guided through the drill sleeves, through the near cortex, through the mid or proximal portions of the screw, and into the far cortex of the lateral bone fragment (FIG. 29). If wire cross fixation is adequate, the cross fixation guide may be removed and the wire may be trimmed flush with the bone surface.

However, if screw cross fixation is desired, a screw depth gauge 352 may be placed over the cross fixation wire to measure the projecting portion of the guide wire to determine the required screw length for bi-cortical fixation (FIG. 30).

A countersink tool 354 may be used to create a countersink for a cross fixation bone screw 356 (FIG. 31).

The appropriate length cross fixation screw 356 may then be guided over the cross fixation wire 350 and seated into the bone (FIG. 32). These steps may be repeated to place additional screws if desired.

FIGS. 33 and 34 illustrate the location of the screw 100 and cross fixation screws 356 relative to the lateral and medial bone fragments.

FIG. 35 illustrates the cross fixation screws 356 in the screw 100 without the bone to obscure the view. Preferably the screw 100 is made of a relatively soft material, e.g. a polymer, that facilitates arbitrary placement of the cross fixation screws at any desired location. 

What is claimed is:
 1. A plurality of headless bone screws comprising: a first bone screw comprising an elongate body having a distal portion and a headless proximal portion spaced longitudinally relative to a longitudinal axis, the distal portion having a helical distal thread formed thereon, the distal thread having a minor diameter, a pitch and a major diameter; and a second bone screw comprising an elongate body having a distal portion and a headless proximal portion spaced longitudinally relative to a longitudinal axis, the distal portion having a helical distal thread formed thereon, the distal thread having a minor diameter, a pitch and a major diameter; the second bone screw distal thread minor diameter being equal to the first bone screw distal thread minor diameter, the second bone screw distal thread pitch being equal to the first bone screw distal thread pitch, and the second bone screw distal thread major diameter being greater than the first bone screw distal thread major diameter; wherein the headless proximal portion of each of the first bone screw and the second bone screw comprises a cylindrical exterior surface that is smooth and unthreaded for an entire length of the headless proximal portion; wherein the helical distal thread of each screw is operable to bend as it is threaded into a bone to follow a curved path in the bone.
 2. The plurality of bone screws of claim 1 further comprising: a third bone screw comprising an elongate body having a distal portion and a proximal portion spaced longitudinally relative to a longitudinal axis, the distal portion having a helical distal thread formed thereon, the distal thread having a minor diameter, a pitch and a major diameter; the third bone screw distal thread minor diameter being equal to the second bone screw distal thread minor diameter, the third bone screw distal thread pitch being equal to the second bone screw distal thread pitch, and the third bone screw distal thread major diameter being greater than the second bone screw distal thread major diameter.
 3. The plurality of bone screws of claim 1 wherein the first bone screw proximal portion has a diameter and the second bone screw proximal portion has a diameter, the second bone screw proximal portion diameter being greater than the first bone screw proximal portion diameter.
 4. The plurality of bone screws of claim 1 wherein the proximal portion includes a transverse through bore through the proximal portion from a first opening on an outer surface of the proximal portion to a second opening on the outer surface of the proximal portion.
 5. The plurality of bone screws of claim 1, wherein, for each of the first and second bone screws: the elongate body has a length; the headless proximal portion has a proximal diameter greater than or equal to the major diameter and is unthreaded for at least 25% of the length; the helical distal thread extends along at least 25% of the length; and the elongate body comprises a middle portion comprising a taper at which a middle diameter of the middle portion diminishes, distally, from the proximal diameter to the minor diameter.
 6. A plurality of headless bone screws comprising: a first bone screw comprising an elongate body having a distal portion and a headless proximal portion spaced longitudinally relative to a longitudinal axis, the distal portion having a continuous helical distal thread formed thereon, the distal thread having a minor diameter, a pitch and a major diameter; and a second bone screw comprising an elongate body having a distal portion and a headless proximal portion spaced longitudinally relative to a longitudinal axis, the distal portion having a continuous helical distal thread formed thereon, the distal thread having a minor diameter, a pitch and a major diameter; the second bone screw distal thread minor diameter being equal to the first bone screw distal thread minor diameter, the second bone screw distal thread pitch being equal to the first bone screw distal thread pitch, and the second bone screw distal thread major diameter being greater than the first bone screw distal thread major diameter; wherein the helical distal thread of each screw is operable to bend as it is threaded into a bone to follow a curved path in the bone.
 7. The plurality of bone screws of claim 6 wherein the first bone screw proximal portion has a diameter and the second bone screw proximal portion has a diameter, the second bone screw proximal portion diameter being greater than the first bone screw proximal portion diameter.
 8. The plurality of bone screws of claim 6 wherein each screw further comprises a helical proximal thread formed on the proximal portion.
 9. The plurality of bone screws of claim 8 wherein the distal thread of each screw has a distal thread pitch and the proximal thread of each screw has a proximal thread pitch, the proximal thread pitch of each screw being equal to the distal thread pitch of the same screw.
 10. The plurality of bone screws of claim 8 wherein the proximal thread of each screw has a major diameter and a minor diameter and a mid-portion of each screw, between the distal thread and the proximal thread, has an outer diameter, the proximal thread minor diameter of each screw being greater than or equal to the mid-portion outer diameter of the same screw and the distal thread major diameter of each screw being less than or equal to the mid-portion outer diameter of the same screw.
 11. The plurality of bone screws of claim 8 wherein the distal thread of each screw has a distal thread pitch and the proximal thread of each screw has a proximal thread pitch, the proximal thread pitch of each screw being different than the distal thread pitch of the same screw.
 12. The plurality of bone screws of claim 6, wherein a ratio of the major diameter to the pitch of each screw is sufficiently low to allow the elongate distal portion to be operable to bend as it is threaded into the bone to follow the curved path.
 13. The plurality of bone screws of claim 6, wherein the proximal portion includes a transverse through bore through the proximal portion from a first opening on an outer surface of the proximal portion to a second opening on the outer surface of the proximal portion.
 14. A plurality of headless bone screws comprising: a first bone screw comprising an elongate body having a distal portion and a headless proximal portion spaced longitudinally relative to a longitudinal axis, the distal portion having a helical distal thread formed thereon, the distal thread having an unbroken minor diameter, a pitch and a major diameter; and a second bone screw comprising an elongate body having a distal portion and a headless proximal portion spaced longitudinally relative to a longitudinal axis, the distal portion having a helical distal thread formed thereon, the distal thread having an unbroken minor diameter, a pitch and a major diameter; the second bone screw distal thread minor diameter being equal to the first bone screw distal thread minor diameter, the second bone screw distal thread pitch being equal to the first bone screw distal thread pitch, and the second bone screw distal thread major diameter being greater than the first bone screw distal thread major diameter; and wherein the helical distal thread of each screw is operable to bend as it is threaded into a bone to follow a curved path in the bone.
 15. The plurality of bone screws of claim 14 wherein each screw further comprises a helical proximal thread formed on the proximal portion.
 16. The plurality of bone screws of claim 4 wherein the distal thread of each screw has a distal thread pitch and the proximal thread of each screw has a proximal thread pitch, the proximal thread pitch of each screw being different than the distal thread pitch of the same screw.
 17. The plurality of bone screws of claim 15 wherein the distal thread of each screw has a distal thread pitch and the proximal thread of each screw has a proximal thread pitch, the proximal thread pitch of each screw being equal to the distal thread pitch of the same screw.
 18. The plurality of bone screws of claim 15 wherein the first bone screw proximal portion has a diameter and the second bone screw proximal portion has a diameter, the second bone screw proximal portion diameter being greater than the first bone screw proximal portion diameter.
 19. The Plurality of bone screws of claim 15, wherein the proximal thread of each screw has a major diameter and a minor diameter and a mid-portion of each screw, between the distal thread and the proximal thread, has an outer diameter, the proximal thread minor diameter of each screw being greater than or equal to the mid-portion outer diameter of the same screw and the distal thread major diameter of each screw being less than or equal to the mid-portion outer diameter of the same screw.
 20. The plurality of bone screws of claim 14, wherein the proximal portion includes a transverse through bore through the proximal portion from a first opening on an outer surface of the proximal portion to a second opening on the outer surface of the proximal portion. 